X-ray Guidance Research Articles

Transjugular liver biopsy: method of choice for taking a biopsy

A transjugular liver biopsy is a route of obtaining a biopsy of the liver for the diagnosis and management of patients with hepatic disease. In this article the author will demonstrate how a liver biopsy via the transjugular route is taken using X-ray guidance and will describe the method step-by-step as it is performed at the Royal Free Hospital. Finally, the indications and advantages of using this method will be considered. This article should increase awareness of what a transjugular liver biopsy is and inform the reader of how a tissue sample is taken, thus enabling further understanding of the procedure. It is concluded that the transjugular route of obtaining a liver biopsy enables a good size and quality of sample to be taken in a safe and effective manner with only one pass (one attempt) being required. This method involves minimal complications and has many advantages.

Interstitial laser photocoagulation and interstitial photodynamic therapy of normal lung parenchyma in the pig.

Interstitial laser photocoagulation (ILP) and interstitial photodynamic therapy (PDT) involve delivery of light to lesions in solid organs using thin fibres passed through needles inserted percutaneously under image guidance. In ILP, the laser energy heats the tissue, whereas in PDT it activates a previously administered photosensitising agent. This study looks at their potential for treating localised, small, peripheral lung cancers in patients unsuitable for surgery. Experiments were undertaken on nine normal pigs, up to four fibres being inserted into the lung parenchyma percutaneously under X-ray guidance (ILP: 2-3 W, 1000 q/fibre, from 805 nm diode laser, PDT, 100-200 J/fibre from 652 nm diode laser at 50-100 W, 3 days after 0.15 mg/kg mTHPC). Animals were killed from 3 days to 3 months later and the treated areas examined macroscopically and microscopically. Both techniques were well tolerated, producing well-defined, localised lesions, typically 3.5 x 2 x 2 cm using four fibres. Histology showed thermal coagulative necrosis after ILP and haemorrhagic necrosis after PDT. Early small haematomas and late cavitation were sometimes seen after ILP, but not after PDT. PDT lesions healed with preservation of larger arteries and bronchi in the treated area. A few small pneumothoraces were seen which resolved spontaneously, probably related to the chest wall puncture. It was concluded that ILP and PDT lesions of a size large enough to cover a small tumour can be made safely in the lung parenchyma, although healing was better after PDT. Pilot clinical studies with both techniques are now justified on carefully selected patients.

In Vivo and in Vitro Experience with the PUCA-II, a Single-Valved Pulsatile Catheter-Pump

The Pulsatile Catheter (PUCA) pump is a trans-arterial pulsatile ventricular assist device that can be used for short-term left ventricular support. The separate inflow and outflow valves in the first version of the device (PUCA-I) were replaced by a single inflow/outflow valve in the latest PUCA pump version (PUCA-II). The new combined valve was tested during in vitro (mock circulation) and in vivo experiments for valve leakage, flow resistance, and thrombus formation. During the in vitro experiments a maximum valve leakage of 6% during ejection and 21% during aspiration was found. The maximum flow resistance coefficient (K) was 4. The animal experiments demonstrated that the PUCA-II could be positioned within a few minutes into the left ventricle without X-ray guidance and without using a vascular graft. Thrombi were not found in the combined valve after total pump time of 3 hours, which proved the good washout of the valve. Initial experiments to position the pump in the right ventricle through the pulmonary artery were successful and contributed to the development of a new application for the device.

Tracking of individual nanocrystals using diffracted x rays

We demonstrated dynamical observation of an individual nanocrystal in supercooled liquid water with the guidance of x-ray diffracted spots from the nanocrystal itself. This new system, which we call diffracted x-ray tracking, monitored small Brownian motions (D=0.68 mrad(2)/s at 233 K) of a single nanoparticle in real time and real space.

A study of sentinel node biopsy in T1 breast cancer treatment: experience of 48 cases.

Axillary clearance in breast cancer has been proven to be unnecessary in more than 50% of cases. Sentinel node biopsy (SNB) is a new technique that can be used to avoid unnecessary axillary clearance in breast cancer surgery. Our integrated team, consisting of surgeons, pathologists and nuclear medicine physicians, studied 48 cases of T1 breast cancer with lymphoscintigraphy-guided SNB. Before starting this study, the team performed 20 SNBs as a learning procedure. 500 microCi of 99mTc-nanocoll in 0.2 mL were injected around the lesion, under US or x-ray guidance if necessary. Static images in anterior, lateral and lateral oblique view collected at the end of a 20 min dynamic study were used to mark the SN on the skin. During surgery a gamma probe was used to guide SN resection, and node invasion was assessed with cytokeratin immunohistochemistry. In 14 patients tracer uptake was observed in a single node, in 30 patients in 2-4 nodes, whereas in four patients the nodes were scintigraphically missed. Surgical resection was possible in 42 nodes out of 54. All but two patients with negative immunohistochemistry for cancer cell clusters showed metastasis-free axillary nodes. All patients with positive SNBs (13) showed involved axilla. In four patients the lymphatic drainage was towards the intramammary chain; one node was juxtaclavicular and one node was intramammary in the upper outer quadrant. The overall sensitivity of the method was about 80%, the specificity about 90% with a diagnostic accuracy about 80%. SNB is a promising method for surgical decision-making regarding axillary clearance in breast cancer. Adequate training of an interdisciplinary team is needed in order to successfully perform SNB and assess SN invasion. Its unusual anatomic location can be encountered and technical care is necessary to correctly identify and remove them.

類骨骨腫に対する低侵襲性手術

Two patients with osteoid osteoma treated by a percutaneous excision under a X-ray-guided technique are described. They include a 13-year-old boy with osteoid osteoma in the femoral neck and a 13-year-old boy with tumor in the tibia. After inserting a Kirschner-wire to the nidus under X-ray guidance, a 7mm-diameter trephine needle was advanced through the wire. Nidus was successfully resected into a fan-shape without causing any problems, and no recurrence was seen. Our technique is simple, safe, and minimum to treat patients with osteoid osteoma.

Dissolution of gallbladder stones with methyl tert-butyl ether and stone recurrence: a European survey.

Since there are now several ways to treat symptomatic gallstone disease, one is able to select treatment on the basis of the patient's comfort, the practicability, effectiveness, and side effects of the technique, and the relative costs. In order to assess the present status of contact dissolution with methyl tert-butyl ether with regard to these aspects, the present enquiry reports the data of 21 European hospitals. Eight hundred three patients were selected for contact litholysis of cholesterol gallbladder stones using methyl tert-butyl ether. Percutaneous transhepatic puncture of the gallbladder was performed under x-ray or ultrasound guidance. Dissolution rate, side effects, and treatment times of 268 patients from one single center were compared to those of 535 patients from the other 20 centers. Two hundred sixty-four patients were followed for five years to assess stone recurrence. Physicians were asked how they assessed the expenditure of the method, the discomfort to the patients, and the staffing situation. Patients were asked to indicate their acceptance on an analog scale. Puncture was successful in 761 (94.8%) patients. Prophylactic administration of antibiotics was not necessary. Stones were dissolved in 724 (95.1%) patients. In 315 (43.5%) sludge remained in the gallbladder. The most severe complication was bile leakage, which led 12 (1.6%) patients to have elective cholecystectomy. Toxic injuries due to the ether were not reported. Method-related lethality amounted to 0%, 30-day-lethality to 0.4%. Stone recurrence rate was about 40% in solitary stones and about 70% in multiple stones over five years. Patients with multiple stones developed recurrent stones almost twice as often as those with solitary stones. The probability of stone recurrence in patients with sludge in the gallbladder after catheter removal was not statistically significantly different from those without sludge. Seventy to 90% of the centers found the puncture to be simple and not distressing for patients and the relation between expenditure and therapeutic success to be acceptable. The acceptance of contact litholysis by the patients was excellent. Contact litholysis when applied by an experienced team provides real advantages in the treatment of gallstone disease. The method is technically simple, well accepted by the patients, and can be easily applied in community hospitals. Contact litholysis may be of particular value in patients who are not suitable for anesthesia or surgery.

Stereotactic Biopsy: Advantages and Limitations

: Percutaneous-needle biopsy of breast lesions has become an accepted method for definitive diagnosis of many women with impalpable breast lesions that are worrisome for carcinoma. The incorporation of this technique into a clinical practice requires that the physician who recommends this procedure and the one who performs it must understand the advantages and limitations it offers in the various clinical settings in which it might be utilized. Percutaneous-needle biopsy can be performed with either x-ray (stereotactic) or ultrasound imaging guidance. The biopsy can be done with fine-needle aspiration to obtain cells for cytology or with coreneedle biopsy to obtain tissue for histologic assessment. This article will review the applications and limitations of stereotactic-needle biopsy (SNB). Because core biopsy is most frequently performed in the United States, stereotactic core needle biopsy (SCNB) will be emphasized.

Delayed Retrieval of Fragment After Needle Breakage During Intracavernous Self-Injection

Intracavernous self-injection of vasoactive drugs for erectile dysfunction is now widespread due to its effectiveness and low rate of complications. We report 2 cases of intracavernous needle breakage with delayed retrieval. CASE REPORTS Case 1. A 69-year-old man presented with a needle fragment in the penis. During self-injection he felt unusual pain, and he discovered that the 28 gauge needle had broken and a portion remained in the penis. An attempt to retrieve it through a 4 cm. incision failed elsewhere 2 hours before hospital admission. There was a large hematoma over the incision but no metal fragment was palpable. Needle position was confirmed by x-ray (fig. 1). The patient was discharged home with instructions to return for followup. Six weeks later the fragment was protruding and palpable beneath the skin. The needle was dislodged through a superficial 1 mm. incision without local anesthesia or x-ray guidance. Case 2. An 80-year-old man presented with a needle fragment in the penis. He felt a sharp pain during the second self-injection for erectile dysfunction, and he then discovered that the 28 gauge needle had broken and a portion was embedded in the penis. A hematoma was present over the injection site but no metal fragment was palpable. Needle position was confirmed by x-ray (fig. 2, A). The patient refused surgical intervention. Four days later he reported needle protrusion beneath the skin. A 1 mm. superficial skin incision was made over the palpable needle point without local anesthesia or x-ray guidance and the fragment slipped out effortlessly (fig. 2, B).

Electrochemical treatment of lung cancer

A pilot study of electrochemical treatment (ECT) as a therapy for 386 patients with nonsmall cell lung cancer was undertaken. There were 103 stage II cases, 89 stage IIIa cases, 122 stage IIIb cases, and 72 stage IV cases. Two ECT methods were used: For peripherally located lung cancer, platinum electrodes were inserted transcutaneously into the tumor under x-ray or CT guidance. For central type lung cancer or for those inoperable during thoracotomy, electrodes were inserted intraoperatively directly into the cancer. Voltage was 6-8 V, current was 40-100 mA, and electric charge was 100 coulombs per cm of tumor diameter. The number of electrodes was determined from the size of cancer mass, because the diameter of effective area around each electrode is approximately 3 cm. The short-term (6 months after ECT) results of the 386 lung cancer cases were: complete response (CR), 25.6% (99/386); partial response (PR), 46.4% (179/386); no change (NC), 15.3% (59/386); and progressive disease (PD), 12.7% (49/386). The total effective rate (CR + PR) was 72% (278/386). The 1, 3, and 5 year overall survival rates were 86.3% (333/386), 58.8% (227/386), and 29.5% (114/386), respectively. The main complication was traumatic pneumothorax, with an incidence rate of 14.8% (57/386). These clinical results show that ECT is simple, safe, effective, and minimally traumatic. ECT provides an alternative method for treating lung cancers that are conventionally inoperable, that are not responsive to chemotherapy or radiotherapy, or that cannot be resected after thoracotomy. Long-term survival rates suggest that ECT warrants further investigation.

Electrochemical treatment of lung cancer

A pilot study of electrochemical treatment (ECT) as a therapy for 386 patients with nonsmall cell lung cancer was undertaken. There were 103 stage II cases, 89 stage IIIa cases, 122 stage IIIb cases, and 72 stage IV cases. Two ECT methods were used: For peripherally located lung cancer, platinum electrodes were inserted transcutaneously into the tumor under x-ray or CT guidance. For central type lung cancer or for those inoperable during thoracotomy, electrodes were inserted intraoperatively directly into the cancer. Voltage was 6–8 V, current was 40–100 mA, and electric charge was 100 coulombs per cm of tumor diameter. The number of electrodes was determined from the size of cancer mass, because the diameter of effective area around each electrode is approximately 3 cm. The short-term (6 months after ECT) results of the 386 lung cancer cases were: complete response (CR), 25.6% (99/386); partial response (PR), 46.4% (179/386); no change (NC), 15.3% (59/386); and progressive disease (PD), 12.7% (49/386). The total effective rate (CR + PR) was 72% (278/386). The 1, 3, and 5 year overall survival rates were 86.3% (333/386), 58.8% (227/386), and 29.5% (114/386), respectively. The main complication was traumatic pneumothorax, with an incidence rate of 14.8% (57/386). These clinical results show that ECT is simple, safe, effective, and minimally traumatic. ECT provides an alternative method for treating lung cancers that are conventionally inoperable, that are not responsive to chemotherapy or radiotherapy, or that cannot be resected after thoracotomy. Long-term survival rates suggest that ECT warrants further investigation. Bioelectromagnetics 18:8–13, 1997. © 1997 Wiley-Liss, Inc.

Aortic Dissection as a Complication of Celiac Plexus Block

Aortic Dissection as a Complication of Celiac Plexus Block

Intrauterine fetal transfusion, 1963-90.

The first fetal transfusion was performed at the National Women's Hospital in Auckland in 1963. From that time until the end of 1990, a total of 1041 transfusions have been completed on 459 fetuses. The survival rate for affected pregnancies rose significantly from 39% in 1963-65 to 90% in 1986-90. The initial 409 patients had fetal transfusions performed via the intraperitoneal cavity with X-ray guidance. Since 1986, 50 pregnancies have been treated with intravascular transfusions under ultrasound guidance and 45 fetuses survived.

Monitoring of mononuclear cell subsets isolated from the coronary sinus and the right atrium in patients after heart allograft transplantation

The rejection of a transplanted heart leads to an accumulation of mononuclear cells in the cardiac tissue and to reactions of the antigen-recognizing cells with the foreign tissue. Consequently, during rejections immunologic changes, such as the number of mononuclear cells and the patterns of mononuclear cell subpopulations, should be detectable by analysis of mononuclear cells from the coronary sinus of transplanted hearts. Seventy-nine endomyocardial biopsies were performed in 37 patients. Severity of graft rejection was classified by the Billingham scheme. Thirty-two biopsy specimens showed no rejection, 33 mild, and 14 moderate rejection. After endomyocardial biopsy the coronary sinus was catheterized under x-ray guidance. Heparinized blood samples were obtained from the coronary sinus and the right atrium, and mononuclear cell counts and subpopulation pattern were compared. Patients without rejection and patients with mild rejection showed no significant differences in the patterns of mononuclear cell subpopulation identified in right atrium blood. However, a significant (1.56-fold) increase of mononuclear cells was assessed in the CS blood (p less than 0.01). Moderate rejections showed a 4.2-fold augmentation of mononuclear cells in the coronary sinus (p less than 0.005) compared with nonrejections. In addition, the T-helper/inducer (CD4) percentage increased from 27.1% in the right atrium to 41.2% in the coronary sinus (p less than 0.005), natural killer cells (CD16) from 17.7% to 31.8% (p less than 0.005), and the interleukin 2 receptor-bearing cells from 6.6% to 15.3% (p less than 0.005). Percentage of pan-T cells (CD3), T-cytotoxic/suppressor cells (CD8), and monocytes (CD14) showed no statistically significant changes. These findings correlated with grading according to endomyocardial biopsy. Using the ratio of values obtained from cells of the coronary sinus and the right atrium rendered the coronary sinus immunologic monitoring independent of changes in the administered immunosuppressive regimen. The specificity of the described method was as good as that of endomyocardial biopsy. It is concluded that the discrimination of the patterns of mononuclear cell subpopulations from right atrium versus coronary sinus blood samples is highly sensitive and allows the correct diagnosis of graft rejection within 1 to 2 hours.

Stereotaxic surgery under X-ray guidance in the rhesus monkey, with special reference to the amygdala

The anterior/posterior (AP) positions of three subcortical regions; the amygdala, supra-optic nucleus of the hypothalamus and mammillary bodies, were estimated with respect to the skull in 35 rhesus monkeys (Macaca mulatta). The distances from the external auditory meatus, from which stereotaxic coordinates are typically derived, to these subcortical nuclei were found to be highly variable. In contrast the posterior tip of the sphenoid bone, which was visualized on lateral radiographs, provided a landmark at a remarkably constant AP distance from these nuclei. This landmark was used to guide a series of a amygdaloid lesions and injections. The accuracy of these operations strongly suggested that the posterior tip of the sphenoid bone could be used to predict not only the AP but also the height of the amygdala. It is proposed that this radiographic technique could be applied to other hypothalamic and basal forebrain regions.

Intrauterine fetal transfusion in 365 fetuses during fifteen years

The results of intrauterine fetal transfusion in 365 consecutive fetuses with erythroblastosis fetalis, between May 1 1964, and December 1979, are reported. The gestational ages of the fetuses at initial transfusion ranged from 22 to 33 weeks. The criteria for transfusion were established by optical density measurements on amniotic fluid supplemented by amniograms and ultrasonography. The transfusions were performed under x-ray and fluoroscopic guidance in the first 330 fetuses and 142 survived (43%). Two hundred fifty-eight of these had no evidence of ascites or hydrops initially and 137 survived (53%). Of the 72 fetuses which had hydrops or ascites, five survived. For the last 35 fetuses treated since January 1978, the procedure has been performed under direct ultrasound guidance with the use of a real-time phased array sector scanner. Seventeen fetuses have survived (49%). Twenty-one of the 35 fetuses had no evidence of ascites or hydrops and 13 survived (62%). Of the 14 fetuses who had hydrops or ascites, four survived.

Percutaneous epidural dorsal column stimulation. Technical note.

✓ The authors describe a method of epidural electrode placement and electrically induced paresthesia localization without x-ray guidance.

Experiences with percutaneous renal biopsy.

609 percutaneous renal biopsies were performed in 473 patients.A renal specimen was obtained in 60 per cent with blind technique, in 65 per cent with X-ray guidance and in 47 per cent with ultrasound technique. By repeating the procedure a specimen was obtained in a total of 90 per cent of patients with a serum creatinine > 30 mg per liter and in 70 per cent of patients with a serum creatinine <30 mg per liter.Macroscopic hematuria was seen in 12 per cent, perirenal hematoma in one per cent. One patient died from bleeding. Arterial hypertension did not increase the number or the severity of the complications.

Note on an Improvised Simultaneous Bi-Plane Fluoroscopy

The frequent occurrence of inhalation of radio-paque foreign bodies into the lungs and their difficult, and sometimes impossible removal without adequate X-ray guidance made me devise the following arrangement now in use in this department.